Earlier the Better

1. Earlier the Better

2. Objectives State what research says about early identification and intervention (EII) & screening Understand the difference between surveillance & screening Learn what developmental and mental health screening tools measure State properties and examples of good and not recommended screening tools Learn about current screening efforts in CA

4. The Impact of Early Environmentson Children’s Developmental CompetenceGeorgetown University Center

5. Foster children-the facts* Studies show that foster children have higher rates of significant developmental delays compared to the national average of 12-17% Children with disabilities are more likely to experience abuse or neglect than other children. *Impact: Children with Disabilities and the Child Welfare System: Prevalence Data, Larson and Anderson http://ici.umn.edu/products/impact/191/over6.html *Rates of Part C Eligibility for Young Maltreated Children, Rosenberg and Smith, http://www.jfkpartners.org/Content/PDF/171365-Part%20C%20Child%20Welfare%20Final%20Report.pdf

6. Screening Can Change a Child’s Life Trajectory

7. Detection rates without screening tools 70% of children with developmental disabilities not identified until school entry (Palfrey el al, JPEDS. 1993) 80% of children with mental health problems not identified (Lavigne et al. Pediatr. 1993)

8. Surveillance VS Screening Informal, yet structured, monitoring of developmental achievements Watch over time Based on doctor’s judgment “Gee, Johnny seems a little late in talking, but let’s watch it. I’m sure he’s fine…..” Validated screening tool used at 9, 18 and 24 or 30 months and as needed “ I ask all my parents to fill out this questionnaire so we can see how Johnny is developing.” (no stigma) “The scores show that we should take another look at Johnny and his speech and language development.”

9. AAP’s Policy on Use of Developmental Screening Tools American Academy of Pediatrics (AAP) recommends using validated developmental screening tools at the well-child pediatric visits as needed and at least three times before a child’s third birthday: At- 9 months 18 months and 24 - 30 months

10. Screening: Developmental Developmental validated screening tools identify delays/disabilities or at risk for: Physical development Socio-emotional development Thinking skills Communication skills (speech/language) Next step- assessment

11. Socio-emotional Screening Tools measure: How young children feel about themselves How they behave How they relate to others, especially people who matter to them Identifies children in need of further assessment Screening: Socio-emotional (mental health)

12. Good Screening Tools* Reliable and valid (.70 & above) Have good sensitivity and specificity (.70 & above)- differentiate between those with & without delay/disability Low literacy level ( parent report tools) Culturally and linguistically appropriate Reasonable to implement in setting Minimal expertise to administer Easy to score * Based on ABCD Screening Academy Initiative

13. Screening Tools That Stand Out From the Rest* Developmental ASQ (Ages and Stages Questionnaire) http://www.agesandstages.com PEDS (Parent’s Evaluation of Developmental Status) http://pedstest.com PEDS-DM (PEDS: Developmental Milestones) http://pedstest.com/dm Socio-emotional ASQ-SE Autism MCHAT * Based on ABCD Screening Academy Initiative

14. Why? Are accurate-at least 70% of infants, toddlers & preschoolers with & without disabilities, delays or developmental problems- backed by solid research Are short, low cost, easy to use and score Rely on parents, so appropriate across many cultures Can be completed in many settings-health, child care, home visit, pre-school, online…

15. Comparison of Tools

16. Denver-II no longer recommended Better and cheaper tools available now Over refers and under identifies (time and $) Costs more and takes longer to administer Needs more highly trained staff The American Academy of Neurology & the Child Neurological Society (2000 statement): “Because of the lack of sensitivity and specificity, the Denver-II (DDST-II) & the Revised Denver Pre-Screening Developmental Questionnaire (R-DPDQ) are not recommended for appropriate primary-care developmental surveillance.”

17. THE CURRENT SYSTEM

18. Where is Screening Happening? Health- physicians, home visiting nurses, school nurses, AAP pilots Pre-school/child care- Head Start and Early Head Start, LA-Up in Los Angeles Local health jurisdictions, including through SART (Screening, Assessment, Referral Treatment Program to ID substance use in pregnant women) – Alameda, San Bernardino First 5- San Diego, Alameda, 10 counties with Special Needs Projects Child Welfare Departments- Orange, San Bernardino, San Diego, Los Angeles, Humboldt….

19. Statewide Screening Collaborative Collaborative of over 15 statewide key partners, including State departments Purpose: “To enhance state capacity to promote and deliver effective and well-coordinated health, developmental and early mental health screenings throughout California”

20. CHDP Health Assessment Guidelines- Screening Section Screening collaborative input To be sent out in April 2009 Guidelines will recommend AAP periodicity Provider notice on billing and reimbursement rates to be provided to CHDP providers

21. Medi-Cal FFS Reimbursement Reimbursement ($54.90) in California is only assured when quality instruments are used correctly a) list CPT code 96110 along with the appropriate code for the visit. b) the 96110 code is limited to one unit per day per beneficiary. This means that no matter how many screens you administer in a single day (e.g., PEDS, plus M-CHAT, etc.), you will not be able to bill multiple units c) MediCal reimburses 96110 at all well-visits through age 17 d) If a separate visit is needed to complete other screens, use 96111 Medi-Cal contact: Richmond Rada: Richmond.Rada@dhcs.ca.gov

22. California Screening Initiative (Late 2009) First 5 Association with other key partners to launch the initiative State discounts will be available for ASQ, ASQ-Se, PEDS, PEDS:DM, CHADIS so far Screening Website being developed Targets CA issues with resources, links, etc Will address 0-36 months and 3-5 years of age Cross-sector framework: health, education, child welfare, child care Early Childhood Information Sharing Toolkit with forms, PowerPoint training being developed

23. How Programs and Communities can help families… Know and use high quality screening tools Use results to move child to assessment and diagnosis, if indicated Share results with others- health, schools, etc. Accept results of others (including parents) if high quality screening tools, e.g. ASQ, PEDS, etc. were used Don’t forget to look at the parents…..

24. Legislative Updates Screening Initiatives • Recap the requirements of the Keeping Children and Families Safe Act of 2003 (P.L. 108-36 and Child Abuse and Prevention and Treatment Act (CAPTA) and IDEA. • Describe the Part C and Child Welfare Systems and Services. • PL- 110-351 • SB-597 • Share the rationale for early developmental screening for children in Child Welfare.

25. INDIVIDUALS WITH DISABILITIES EDUCATIONACT - PART C Child Abuse Prevention Treatment Act and

26. DSS now acknowledges that: States receiving CAPTA funds must develop and implement “provisions and procedures for referral of a child under the age of 3 who is involved in a substantiated case of abuse or neglect to early intervention services funded under part C of the Individuals with Disabilities Education Act” [106(b)(2)(A)(xxi)].

27. California’s Implementation All County Letter #06-54 identified strategies: Local level identify multiple pathways (agencies) for collaboration of services Develop agreements, understanding of roles & responsibilities – screening, evaluation, referral Standardize referral form/packets Identify appropriate screening tools for use (Studies show an appropriate tools = a validated screening tool). - Increase knowledge of EI and CW staff

28. And finally, we know that: Under IDEA, mirrors CAPTA. States must provide “a description of the State policies and procedures that require the referral for early intervention services under Part C of a child under the age of 3 who is involved in a substantiated case of c abuse or neglect”

29. Interpretation … Intent of the law: CWS children will receive special attention to determine whether an early intervention referral is needed. See Child Welfare Policy Manual www.acf.hhs.gov/j2ee/programs/cb/laws_policy/laws/cwpm/index.jsp

30. Why bridge connections between child welfare and Part C? Highest rates of abuse and neglect occur in infants and toddlers 16.1 per 1000 children under age 3 High rates of developmental delay in this population 23-61% of children known to CW have delays in development, communication, behavior

31. Public Law -110-351 TITLE IV PART B —Child And Family Services

32. Senate Bill 597 Proposed Statutory Language

33. Rationale for early developmental screening for children in Child Welfare

34. Important Facts To Remember • Exposure to Adverse Childhood Events (ACEs) is associated with increased risk of health, mental health, and social disorders for decades after they occur. • Early recognition of childhood abuse and appropriate intervention may thus play an important role in the prevention of these disorders throughout life. 

35. Resources Properties of a good development screening tool http://www.medicalhomeinfo.org/Screening/DPIP/tools.ppt#579,2,Learning Objectives A compendium of developmental screening and assessment tools with an emphasis on social emotional development, 0-5 years of age http://www.nectac.org/~pdfs/pubs/screening.pdf How to implement effective validated screening in primary care http://www.developmentalscreening.orghttp://www.dbpeds.org Resources for office, provider and parents to implement screening http://www.nashp.org/_docdisp_page.cfm?LID=2A7898BB-5310-11D6-BCF000A0CC558925http://www.medicalhomeinfo.org/Screening/DPIP%20Follow%20Up.html

36. Resources American Academy of Pediatrics policies http://aappolicy.aappublications.org CDC Resources and other links on Developmental Screening http://www.cdc.gov/ncbddd/child/devtool.htm Does Early intervention work? http//:che.georgetown.edu

37. THE POWER OF EARLY INTERVENTION And Beauty of

38. Thank you!

39. Janet Hill, MS, RD, IBCLC Janet.Hill@cdph.ca.gov 916.650.0366